Twelve-Step Liposuction for lipedema Reimbursement Plan

1. Education/Brief Overview of lipedema
   1. Lipedema is a condition in which there is a pathological deposition of fatty tissue, usually below the waist, leading to progressive leg enlargement.
   2. There is no cure for lipedema.
   3. Lipedema does not respond well to diet and exercise.
   4. It is the only available treatment for lipedema after all conservative measures have been exhausted.
2. Document the procedure as Reconstructive
   1. Confirm and document that “Lymph-Sparing, Tumescent Liposuction (LS-TL) is reconstructive and not cosmetic. Emphasize it is to:
   2. Improve normal function (mobility)
   3. Restore to a normal appearance
   4. Improve quality of life (QOL).
   5. Address any comorbidities.
   6. Do not include the psychological benefits from the procedure. This is statutorily documented in numerous policies as “not supporting medical necessity.” No matter how important you feel it is, skip it.
3. Hurdles
   1. Most everyone still thinks of liposuction as merely cosmetic. This includes the general public, physicians, insurance companies and even medical review boards (IRB). For that reason I use the phrase Lymph-Sparing, Tumescent Liposuction.
   2.  Understand that some surgeons may refuse to file or dissuade you from filing a claim. Many will assert it is “never” paid; that’s not true. Their staff may be unfamiliar with appeals. You may have to file the claim and appeal yourself.
   3. You may not be able to find a qualified, board-certified plastic surgeon trained specifically in liposuction for lipedema in-network. You need ask your Provider and the carrier for an “out of network exception.”
   4. Not all carriers, carrier review boards, or provider reps are made equal; some will be much more knowledgeable than others. You won’t win every appeal; some will be incredibly difficult to appeal and others much easier.
   5. Not every case will warrant payment; if you have comorbidities, or if impairment to function and mobility cannot be illustrated, you may not be eligible.
4. Medical Necessity
   1. Get letters and a confirmed diagnosis of lipedema from all your Providers: primary care physician, plastic surgeon, cardiologist, endocrinologist, orthopedic doctor, podiatrist, and anyone else who can help document and prove the medical necessity of the procedure. Be sure to focus on: Restore, Function, Quality of Life, and Comorbidities.
   2. Note that in the 2020 ICD-10-CM there is no specific code for lipedema. For now (MAR 2020) go with R60.9 or Q82.0. More detail is provided in the ICD-10 Coding Post.
5. Provide evidence that LS-TL is not experimental, investigative or unproven.
   1. Confirm and support LS-TL as not experimental, investigative, or unproven (not medically necessary).
   2. Note that unproven can be defined differently than the other two above (per United HealthCare). Some carriers combine the three; some don’t; some carriers are more sophisticated in their evaluations than others.
6. Read Your Insurance contract/plan
   1. Read your carrier manual or contract for cosmetic exclusions, definitions and Evidence of Coverage information. Scour it for the terms liposuction and lipedema.
   2. See if they specifically reference liposuction for lipedema. Some carriers don’t reference liposuction at all; others don’t reference it in regard to lipedema. It is important to determine where your carrier is “on the curve.” Cigna has a fifteen-page coverage denial policy with references to over 25 research papers; others have nothing. If the carrier has a denial policy, you will need to address their concerns and support your appeal with research literature.
7. File your Claim
   1. File the medical insurance claim. Ask the clinic to obtain a pre-authorization and get either a denial reason or approval. Even if they deny the pre-authorization, if you feel you have a good reconstructive, medically necessity case, I would file the claim.
8. Appeal Denial
   1. Expect to be denied at least once. Most have multiple appeal levels (Medicare has specifically five levels).
   2. I have included an entire set of appeal letters and documents, in both .doc and .txt format so you can cut and paste and edit to suit your unique needs.
9. Research to support Medical Necessity
   1. Include all relevant research to support liposuction for lipedema as constructive and medically necessary.
   2. Be aware of common reasons for dismissing research: findings not consistent, lack of a comparator group, small patient size, loss of patients to long-term follow-up, and unproven. This will be the most difficult part for a layman. Work with your provider and lipedema support groups.
10. Comorbidities
    1. Address comorbidities (pre-existing conditions) and any safety issues that may preclude this patient as a candidate for the surgical procedure.
    2. In one appeal denial (Kaiser, 2014) the argument was simply that the surgeon did not effectively address the potential harm to the patient (even potential death) and that the risk did not warrant the procedure.
11. Associations
    1. Please feel free to share this information to everyone involved with liposuction (LS-TL) for lipedema. Encourage them to change/add verbiage on their website and papers to reflect the procedure as reconstructive and medically necessary.
12. Expert Opinions / Comparables
    1. I will be collecting expert opinions on the value and efficacy of LS-TL for lipedema. I plan to maintain a list of insurance companies, and countries that pay or deny LS-TL as well as expert opinions of those who feel the research supports medical necessity.
    2. One secondary argument is using comparable procedures (breast reconstruction, panniculectomy [tummy tuck] and cleft palate repair) to liposuction for lipedema that are covered as reconstructive and medically necessary.
    3. Breast reconstruction is reimbursed nationwide primarily based on federal and state statutes; cleft palate surgery is mandated in about 15 states; the tummy tuck (panniculectomy) procedure is most similar to liposuction as most carriers consider it cosmetic, deny it–but if you can prove its reconstructive, on appeal, some will pay for it.

If all appeals fail, the last resort is a legal action: a class action suit against the carrier (California is best) based on “bad-faith” and breach of contract. ( I guess that is the number 13!)